Nutritional Assessment in Cancer Patients.

Malnutrition in cancer patients is highly prevalent. The metabolic and physiologic changes associated with the disease and the side effects of treatment regimens all combine together to produce a detrimental effect on the patient's nutritional status. A poor nutritional status significantly reduces the efficacy of treatment methods and the patient's overall chances of survival. Therefore, an individualized nutrition care plan is essential to counter malnutrition in cancer. Nutritional assessment is the first step of this process which sets the foundation for developing an effective intervention plan. Currently, there is no single standard method for nutritional assessment in cancer. Hence, to get a true picture of the patient's nutritional state, a comprehensive analysis of all aspects of the patient's nutritional status is the only reliable strategy. The assessment includes anthropometric measurements and evaluation of body protein status, body fat, inflammation markers, and immune markers. A thorough clinical examination which factors in the medical history and physical signs, along with the dietary intake patterns of the patient, is also important components of nutritional assessment of cancer patients. To facilitate with the process, various nutritional screening tools like patient-generated subjective global assessment (PGSGA), nutrition risk screening (NRS), and malnutrition screening tool (MST) have been developed. While these tools have their own benefits, they only give a glimpse of the nutritional problems and do not bypass the need for a complete assessment employing various methods. This chapter covers all four of the elements of nutritional assessment for cancer patients in detail.

Efficient optimization techniques for resource allocation in UAVs mission framework.

This paper considers the generic problem of a central authority selecting an appropriate subset of operators in order to perform a process (i.e. mission or task) in an optimized manner. The subset is selected from a given and usually large set of 'n' candidate operators, with each operator having a certain resource availability and capability. This general mission performance optimization problem is considered in terms of Unmanned Aerial Vehicles (UAVs) acting as firefighting operators in a fire extinguishing mission and from a deterministic and a stochastic algorithmic point of view. Thus the applicability and performance of certain computationally efficient stochastic multistage optimization schemes is examined and compared to that produced by corresponding deterministic schemes. The simulation results show acceptable accuracy as well as useful computational efficiency of the proposed schemes when applied to the time critical resource allocation optimization problem. Distinguishing features of this work include development of a comprehensive UAV firefighting mission framework, development of deterministic as well as stochastic resource allocation optimization techniques for the mission and development of time-efficient search schemes. The work presented here is also useful for other UAV applications such as health care, surveillance and security operations as well as for other areas involving resource allocation such as wireless communications and smart grid.

The intelligent modelling and optimization of an economic and ecosystem-friendly model for grid connected prosumer community.

The establishment of grid-connected prosumer communities to bridge the demand-supply gap in developing nations, especially in rural areas will assist to minimize the use of carbon enriched fossil fuels and the resulting economic pressure. In the promoted study, an economic and ecosystem-friendly hybrid energy model is proposed for grid-connected prosumer community of 147 houses in district Kotli, AJK. The grid search algorithm-based HOMER software is used to simulate and analyze the load demand and biomass sources-based onsite collected data through a survey for an optimal proposed design. The research objectives are to minimize the net present cost (USD) of design, the per unit cost of energy (USD/kWh), and the carbon emissions (kgs/year). A sensitivity analysis based on photovoltaic module lifetime is also performed. The simulations show that the per unit cost of energy is reduced from 0.1 USD/kWh to 0.001 USD/kWh for the annual energy demand (kWh/year) of the community. The number of carbon emissions is also minimized from 122056 kgs/year to 1628 kgs/year through the proposed optimal energy model.

Smartphone Ownership, Smartphone Utilization, and Interest in Using Mental Health Apps to Address Substance Use Disorders: Literature Review and Cross-sectional Survey Study Across Two Sites.

BACKGROUND: In recent years, there has been increasing interest in implementing digital technologies to diagnose, monitor, and intervene in substance use disorders. Smartphones are now a vehicle for facilitating telepsychiatry visits, measuring health metrics, and communicating with health care professionals. In light of the COVID-19 pandemic and the movement toward web-based and hybrid clinic visits and meetings, it has become especially salient to assess phone ownership among individuals with substance use disorders and their comfort in navigating phone functionality and using phones for mental health purposes. OBJECTIVE: The aims of this study were to summarize the current literature around smartphone ownership, smartphone utilization, and the acceptability of using smartphones for mental health purposes and assess these variables across two disparate substance use treatment sites. METHODS: We performed a focused literature review via a search of two academic databases (PubMed and Google Scholar) for publications since 2007 on the topics of smartphone ownership, smartphone utilization, and the acceptability of using mobile apps for mental health purposes among the substance use population. Additionally, we conducted a cross-sectional survey study that included 51 participants across two sites in New England-an inpatient detoxification unit that predominantly treats patients with alcohol use disorder and an outpatient methadone maintenance treatment clinic. RESULTS: Prior studies indicated that mobile phone ownership among the substance use population between 2013 and 2019 ranged from 83% to 94%, while smartphone ownership ranged from 57% to 94%. The results from our study across the two sites indicated 96% (49/51) mobile phone ownership and 92% (47/51) smartphone ownership among the substance use population. Although most (43/49, 88%) patients across both sites reported currently using apps on their phone, a minority (19/48, 40%) reported previously using any apps for mental health purposes. More than half of the participants reported feeling at least neutrally comfortable with a mental health app gathering information regarding appointment reminders (32/48, 67%), medication reminders (33/48, 69%), and symptom surveys (26/45, 58%). Most patients were concerned about privacy (34/51, 67%) and felt uncomfortable with an app gathering location (29/47, 62%) and social (27/47, 57%) information for health care purposes. CONCLUSIONS: The majority of respondents reported owning a mobile phone (49/51, 96%) and smartphone (47/51, 92%), consistent with prior studies. Many respondents felt comfortable with mental health apps gathering most forms of personal information and with communicating with their clinician about their mental health. The differential results from the two sites, namely greater concerns about the cost of mental health apps among the methadone maintenance treatment cohort and less experience with downloading apps among the older inpatient detoxification cohort, may indicate that clinicians should tailor technological interventions based on local demographics and practice sites and that there is likely not a one-size-fits-all digital psychiatry solution.

Arsenic contamination, induced symptoms, and health risk assessment in groundwater of Lahore, Pakistan.

The purpose of this study is to evaluate the arsenic concentration and related health risks in groundwater extracted from tube wells. The physicochemical parameters, including arsenic (As), were investigated using standard procedures. The parameters were found within the permissible limits except for arsenic, which was 78 µg/L. Unfortunately, 82% of the collected water samples were found contaminated with arsenic and exceeded the permissible limit set by the world health organization (10 µg/L). The water intake and its relationship between arsenic concentration, time, and induced symptoms in the study area residents were observed. Skin pigmentation, skin irritation, and numbness of the body were recognized as the major symptoms, and these symptoms were significantly correlated with p-value ˂ 0.05. In comparison, individuals who intake As-contaminated water (> 50 µg/L) for a duration of > 20 years show severe symptoms. Furthermore, health risk assessment associated with arsenic in terms of chronic daily intake (CRI), hazard quotient (HQ), and cancer risk assessment probability (CR) in groundwater was also studied. The HQ of arsenic was 7.46, and the CR value of As on Ravi road was as high as 0.00149, which indicates a possibility of cancer risk in the community Ravi road, Lahore. Based on the findings, the study area needs special monitoring and management of groundwater to reduce health risks associated with contaminated drinking water. Moreover, suitable remediation methods for removing arsenic should be adopted to avoid arsenic exposure and related health risks.

Scaling the great wall: The impact of communication barriers on quality of psychiatric care in Chinese patients.

BACKGROUND: Racial and ethnic minorities (such as Chinese-speaking (CS)) are known to have less equitable access to mental health services than Caucasians. These disparities have a powerful influence on minority groups that already endure a greater burden from mental health needs. AIM: The aim was to identify perceived provider barriers to care for CS patients. METHODS: The study involved an 11-item web-based survey to multidisciplinary health professionals in the department of psychiatry at a 75-bed teaching community mental health center. RESULTS: More than half the respondents agreed that there are disparities in the management of CS versus non-CS patients primarily due to the language barrier (46%). However, older participants and participants who worked fewer hours per week in patient care were less likely to agree (rho = -.27, p = .05 and rho = .33, p = .015, respectively) that these perceived difficulties prevented them from caring for these patients. CONCLUSION: The study revealed that certain modifiable factors like the limited availability of interpreters and culturally appropriate services, rendering psychoeducation and forming therapeutic alliances with CS patients, posed the greatest challenges on inpatient units. In light of these findings, we aim to make recommendations to remediate concerns of limited provider availability by proposing ways to efficiently utilize current resources and advocate for better staffing to improve the overall well-being of this challenging patient subset.

Enhancing an HIV index case testing passive referral model through a behavioural skills-building training for healthcare providers: a pre-/post-assessment in Mangochi District, Malawi.

INTRODUCTION: Although knowledge of HIV positivity is a necessary step towards engagement in HIV care, more than one quarter of HIV-positive Malawians remain unaware of their HIV status. Testing the sexual partners, guardians and children of HIV-positive persons (index case finding or ICF) is a promising way of identifying HIV-positive persons unaware of their HIV status. ICF can be passive where the HIV-positive individual (index) invites a partner (or contact) for HIV testing or active where a health provider assists the index with partner notification and offers HIV testing to the partner. Strategies to improve passive ICF have not been thoroughly studied. We describe the impact of a behavioural skills-building training to enhance healthcare workers' (HCWs) implementation of Malawi's passive ICF programme. METHODS: In June 2017, HCWs from 36 health facilities in Mangochi were oriented to Malawi's ICF programme and began implementation. In February and April 2018, a total of 573 HCWs from these facilities received further training from the Tingathe Programme. The training focused on eliciting more untested sexual contacts from indexes and better equipping indexes on issuing "family referral slips" to contacts. Monthly programmatic data were abstracted from clinical registers from October 2017 to July 2018. Monthly programmatic indicators were collected from the Index Case Testing Register and the HIV Counselling and Testing Register and were entered into a data set with one record per facility per month. T-tests were used to compare the means of these indicators. RESULTS: During the ten-month study period, there were 200 facility-months observed before and 124 facility-months observed after training. The mean number of indexes identified per facility-month remained stable after training (pre = 18.9, post = 21.2, p = 0.74), but the mean number of sexual partners listed per facility-month (pre = 6.3, post = 10.6, p < 0.001) increased. The mean number of contacts who received HIV testing (pre = 11.1, post = 24.8, p < 0.001) and the mean number of HIV-positive contacts identified per facility-month (pre = 1.3, post = 2.3, p < 0.001) also increased. CONCLUSIONS: A brief behavioural skills-building training impacted a range of meaningful outcomes, including identification of HIV-positive individuals in a passive ICF programme. Such approaches could facilitate the identification of HIV-positive persons unaware of their HIV status, a necessary step for engagement in HIV care.

Multimonth Prescription of Antiretroviral Therapy Among Children and Adolescents: Experiences From the Baylor International Pediatric AIDS Initiative in 6 African Countries.

BACKGROUND: To reach 90-90-90 targets, differentiated approaches to care are necessary. We describe the experience of delivering multimonth prescription (MMP) schedules of antiretroviral therapy (ART) to youth at centers of excellence in 6 African countries. METHODS: We analyzed data from electronic medical records of patients aged 0-19 years started on ART. Patients were eligible to transition from monthly prescribing to MMP when clinically stable [improving CD4, viral load (VL) suppression, or minimal HIV-associated morbidity] and ART adherent (pill count 95%-105%). Patients were classified as transitioned to MMP after 3 consecutive visits at intervals of >56 days. We used survival analysis to describe death and lost to follow-up. We described adherence and acceptable immunologic response by CD4 using 6-month and VL suppression (<400 copies per milliliter) using 12-month intervals. RESULTS: Twenty-two thousand six hundred fifty-eight patients aged 0-19 years received ART and 14,932 (66%) transitioned to MMP between 2003 and 2015. Of these 2.6% were lost to follow-up and 2.0% died. Median duration of MMP was 3.9 (interquartile range: 2.2-5.9) years. There were significant differences in survival (P < 0.0001) between age groups, worst among those younger than 1 year and 15-19 years. The frequency of favorable clinical endpoints was high throughout the first 5 years of MMP, by year ranging from 87% to 94% acceptable immunologic response, 75% to 80% adherent, and 79% to 85% VL suppression. CONCLUSIONS: These analyses from 6 African countries demonstrate that youth on ART who transitioned to MMP overall maintained favorable outcomes in terms of death, retention, adherence, immunosuppression, and viral suppression. These results reassure that children and adolescents, who are clinically stable and ART adherent, can do well with reduced visit frequencies and extended ART refills.

Validation of a GPU-Based 3D dose calculator for modulated beams.

A superposition/convolution GPU-accelerated dose computation algorithm (the Calculator) has been recently incorporated into commercial software. The algorithm requires validation prior to clinical use. Three photon energies were examined: conventional 6 MV and 15 MV, and 10 MV flattening filter free (10 MVFFF). For a set of IMRT and VMAT plans based on four of the five AAPM Practice Guideline 5a downloadable datasets, ion chamber (IC) measurements were performed on the water-equivalent phantoms. The average difference between the Calculator and IC was -0.3 ± 0.8% (1SD). The same plans were projected on a phantom containing a biplanar diode array. We used the forthcoming criteria for routine gamma analysis, 3% dose-error (global (G) normalization, 2 mm distance to agreement, and 10% low dose cutoff). The γ (3%G/2 mm) average passing rate was 98.9 ± 2.1%. Measurement-guided three-dimensional dose reconstruction on the patient CT dataset (excluding the Lung) resulted in a similar average agreement rate with the Calculator: 98.2 ± 2.0%. The mean γ (3%G/2 mm) passing rate comparing the Calculator to the TPS (again excluding the Lung) was 99.0 ± 1.0%. Because of the significant inhomogeneity, the Lung case was investigated separately. The calculator has an alternate heterogeneity correction mode that can change the results in the thorax for higher-energy beams (15 MV). As this correction is nonphysical and was optimized for simple slab geometries, its application leads to mixed results when compared to the TPS and independent Monte Carlo calculations, depending on the CT dataset and the plan. The Calculator vs. TPS 15 MV Guideline 5a IMRT and VMAT plans demonstrate 96.3% and 93.4% γ (3%G/2 mm) passing rates respectively. For the lower energies, which should be predominantly used in the thoracic region, the passing rates for the same plans and criteria range from 98.6 to 100%. Overall, the Calculator accuracy is sufficient for the intended use.

Lost opportunities to identify and treat HIV-positive patients: results from a baseline assessment of provider-initiated HIV testing and counselling (PITC) in Malawi.

OBJECTIVE: To assess implementation of provider-initiated testing and counselling (PITC) for HIV in Malawi. METHODS: A review of PITC practices within 118 departments in 12 Ministry of Health (MoH) facilities across Malawi was conducted. Information on PITC practices was collected via a health facility survey. Data describing patient visits and HIV tests were abstracted from routinely collected programme data. RESULTS: Reported PITC practices were highly variable. Most providers practiced symptom-based PITC. Antenatal clinics and maternity wards reported widespread use of routine opt-out PITC. In 2014, there was approximately 1 HIV test for every 15 clinic visits. HIV status was ascertained in 94.3% (5293/5615) of patients at tuberculosis clinics, 92.6% (30,675/33,142) of patients at antenatal clinics and 49.4% (6871/13,914) of patients at sexually transmitted infection clinics. Reported challenges to delivering PITC included test kit shortages (71/71 providers), insufficient physical space (58/71) and inadequate number of HIV counsellors (32/71) while providers from inpatient units cited the inability to test on weekends. CONCLUSIONS: Various models of PITC currently exist at MoH facilities in Malawi. Only antenatal and maternity clinics demonstrated high rates of routine opt-out PITC. The low ratio of facility visits to HIV tests suggests missed opportunities for HIV testing. However, the high proportion of patients at TB and antenatal clinics with known HIV status suggests that routine PITC is feasible. These results underscore the need to develop clear, standardised PITC policy and protocols, and to address obstacles of limited health commodities, infrastructure and human resources.

Burden of illness among patients with fragile X syndrome (FXS): a Medicaid perspective.

BACKGROUND: Fragile X syndrome (FXS) is an inherited intellectual disability that imposes a substantial clinical and humanistic burden on patients and caregivers. This study aimed to quantify the incremental burden of illness following FXS diagnosis in Medicaid populations. METHODS: A retrospective matched-cohort study was conducted using FL, NJ, MO, IA, and KS Medicaid claims (1997-2012). Patients with FXS were matched 1:5 to a comparison group without FXS, based on age, gender, state, and continuous Medicaid coverage. Healthcare resource utilization and costs were compared among cohorts over 1 year following first diagnosis. RESULTS: Overall, 697 patients with FXS were matched to 3485 non-FXS patients. Median age was 12.0 years; 82% were male. Newly diagnosed FXS patients were younger (median age: 7.0 years). During the follow-up, patients with FXS had significantly higher medication use, medical procedure use, medical specialist visits, and associated costs than the non-FXS comparison group. One-fourth of FXS patients filled prescriptions for stimulants, antipsychotics, or anticonvulsants; 25% of patients with FXS had speech and language therapy and 39% had physical therapy (versus 9%, 4% and 8%, respectively, for the comparison group). At least 44% of FXS patients visited a neurologist, cardiologist, otolaryngologist, or gastroenterologist; 92% of patients with FXS had an outpatient visit, 35% had an emergency room visit, and 34% used home services (compared to 31%-32%, 64%, 27%, and 10%, respectively, for the comparison group) (all p < 0.05). Patients with FXS had an incremental annual total healthcare cost of $33,409 (2012$) per person relative to the comparison group, while newly diagnosed FXS patients had incremental total annual healthcare costs of $17,617 (2012$) per person. CONCLUSIONS: Both established and newly diagnosed FXS were associated with significantly increased use of multiple medications and medical services, and increased healthcare costs. Treatments that could help reduce this disease burden are urgently needed.

Delivering pediatric HIV care in resource-limited settings: cost considerations in an expanded response.

If children are to be protected from HIV, the expansion of PMTCT programs must be complemented by increased provision of paediatric treatment. This is expensive, yet there are humanitarian, equity and children's rights arguments to justify the prioritization of treating HIV-infected children. In the context of limited budgets, inefficiencies cost lives, either through lower coverage or less effective services. With the goal of informing the design and expansion of efficient paediatric treatment programs able to utilize to greatest effect the available resources allocated to the treatment of HIV-infected children, this article reviews what is known about cost drivers in paediatric HIV interventions, and makes suggestions for improving efficiency in paediatric HIV programming. High-impact interventions known to deliver disproportional returns on investment are highlighted and targeted for immediate scale-up. Progress will carry a cost - increased funding, as well as additional data on intervention costs and outcomes, will be required if universal access of HIV-infected children to treatment is to be achieved and sustained.